Deficiency of oestrogen may also lead to dysuria (burning sensation when passing urine), urinary urgency, frequency and incontinence (the genitourinary syndrome of menopause).

Bacteria in the vagina

Lack of oestrogen causes changes in the normal vaginal organisms. Those seen in younger women (especially lactobacilli) disappear and are replaced by gram negative organisms such as Escherichia coli or those associated with bacterial vaginosis. Urinary or bladder infections are more common in postmenopausal women than in younger women.

What does an atrophic vulva and vagina look like?

Atrophic vulvovaginitis changes the appearance of the female genitalia:

Vulva appears paler

Labia are thinner and smaller

Clitoral hood is less obvious

A red membrane or polyp may be visible at urethral opening (urethral caruncle)

The vaginal skin looks thin and dry, with tiny blood vessels under it resulting in patchy redness

Stretching the vulva may cause splitting of the skin at the bottom of the vagina or elsewhere.

Should any tests be done to confirm the diagnosis?

Tests may be performed in atrophic vulvovaginitis if any symptoms are present. These may include:

Skin swab / wet mount examination – this may reveal epithelial cells typical of postmenopausal vagina may be reported and can help identify infection

Biopsy – this may be done to make sure there is not an inflammatory skin disease or neoplastic condition causing symptoms

Cystoscopy of the bladder and investigations for urinary symptoms

Colposcopy of the vagina and cervix and investigations for gynaecological symptoms.

General measures to improve atrophic vulvovaginitis

The following measures are recommended.

Use a non-soap cleanser or gently wash with warm water alone, no more than once or twice daily

Oestrogen treatment

Atrophic vulvovaginitis is treated with topical oestrogen, a prescription medicine. This can be provided as vaginal cream, pessaries or vaginal ring. In New Zealand, Ovestin™, which contains oestriol, is used in a dose of 0.5 mg/day for 1–2 weeks then once or twice weekly. It can be inserted with an applicator or on a fingertip. Vagifem™ pessaries (containing oestrodiol) can also be used but are not currently funded by PHARMAC in New Zealand.

Oestrogen treatment results in:

Normalisation of vaginal wall cells

Improved vaginal blood flow

Decreased vaginal pH

Re-colonisation by lactobacilli

Improve vaginal thickness and elasticity

Reduction in vulvovaginal symptoms

Improved sexual function

Reduced urinary infections.

Topical oestrogen is considered safe because very little is absorbed systemically. However, it is not usually prescribed to women with severe liver disease, oestrogen-dependent cancers or thromboembolic disease in case it increases the risk of these conditions.

Other forms of oestrogen are sometimes recommended including tablets, transdermal patches, gels, sprays and emulsions. Systemic oestrogen is usually mixed with progestogens. There are important risks and side effects so they are not usually used if atrophic vaginitis is the only problem.